• Document No.

  • Lockout/Tagout Periodic Inspection

  • Manufactured Packaging Products

  • Conducted on

  • Prepared by Cristina Cook

  • Co-workers Present

Pre-certification Prepared by trainer/supervisor

  • Co-worker has been trained in MPP LOTO procedures for assigned task

  • Co-worker can identify all stored & kinetic energy sources of equipment<br>

  • Co-worker has been issued locks, keys, hasp, and tags as needed and appropriate.

  • All locks are unaltered and uniform with plant standards; clearly identify ownership

  • Observed Employee

  • Supervisor/Trainer

Lockout/Tagout Process

  • Step 1- Identify energy sources

  • Step 2- Notify others (affected Co-workers and other personnel in area)

  • Step 3- Shut down the equipment using normal stopping procedures for the equipment<br>

  • Step 4- isolate the equipment from the energy source

  • Step 5- Lock out the equipment by affixing locks to each energy sources controlling device

  • Step 6- Release stored energy (electrical, mechanical, hydraulic pneumatic, chemical, thermal, etc)

  • Step 7- Ensure area is clear of all personnel and verify isolation<br>

  • Step 8- Perform servicing

  • Step. 9- Release the equipment from lockout/tagout


  • Co-worker was able to conduct Lockout/Tagout process correctly and all steps were conducted sequentially

  • Co-worker demonstrates ability and knowledge to properly conduct lockout/tagout when necessary

  • Co-worker understands that he/she will be subject to periodic audits as deemed necessary by management<br>

  • Co-worker understands that violation of lockout/tagout policy can and will result in disciplinary action, up to and including termination

  • Auditor Signature

  • Supervisor Signature

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